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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAsr HAZELTOv AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADORESs Application 1 of 2: 1181 Zuckerman Rd Ctrr/ZIP_S'Locktxr , CA 95206 <br /> 0 <br /> CR033$TAFFY ACCESS Road qpN 129'93'1 1312 PARCEL SIZE �AND U3E APPUGATIGNA O <br /> m <br /> OWNER NAME PdClf 1C Gas & El ecC ric Company PtLZ• ,,,,��/TB(��rent Maeda PHONE (925) 328-5637 <br /> OWNERAODRESs 6121 Bollinger Canyon Rd ft 1(7uVvg1TY/STATE/ZIP San Ramon, CA 94583/-5• <br /> CONTRACTOR American Construction and SuoplY Inc PHONE (415) 927-2024 <br /> CONTRACTOR ADDRE33 45 San Clement Drive SuiLe A-100 CITY/STATEMP Corte Madera CA 94925 <br /> SUBCONTRACTOR N/A PHONE <br /> SUBCONTRACTOR ADORE3s CrTY/STATE/Z!P <br /> LICENSE X C-57 _ C-61 D-09 - Other NUMBER 310599 E%PIRATON DATE 03/31/2019 <br /> GEOGRAPHICAL INFORMATION: Coordinates 37.988229 Y -121.479492 Townshlp02U Range 04E Section 25 <br /> INTENDED UsE DomestirtPrivate -Imgation/Agricultural Industrial -Water Quality Monitoring _Soil Sampling/Characterization <br /> - Pubfic Water System <br /> I/011M,R from Owrwr a ei y em artr o ama cr r>s u <br /> TYPEOFWORK XNewWell _ Replacement Well _ Well A)teration/Mod"Ication XOther Cathodic Protection <br /> MonitoringWells R of wells X Soil Boring(s)s e°r°ort <br /> O 9O r9a . Geotechnical epbon <br /> Out-Of-Service Well Out-Of-Service Well Renewal _Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTioN <br /> Drilling Method Mud Rotary Air Rotary X Auger Cable Tool - Push Point Other <br /> Proposed Well Depth 15 It Excavation 10 __in diameter Open Bottom Gravel PacldGravel Size in diameter <br /> Condudor Casing N/A in diameter I Conductor Casing Depth R <br /> Well Casing Diameter N/A in Thickness/Gauge/ASTM Sched N/A Steel - Plastic Stainless Steel Other Prone _ <br /> Grout Seal Depth 2 ft X Neat Cement(94 lb Dag/5-f0 ga water, Sand Cement sack mrzl7 gal water <br /> - Bentonite(20%solids) Other <br /> Grout Placement Method -_Pumped X Free Fall ._Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller ..Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width R Length ftThick in X Christy Box Stove Pipe <br /> MP Submersible Turbine Other HP Pump Set It Standing Water Level fl <br /> 1 HEREBY CERTIFY THAT I HAEPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDfNANCW. STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br /> WORKERS COMPENSATION LAW//S. <br /> __MINIMUM 24 791 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED 1 Steve McKim TITLE Vice President DATE 04/C4/2017 <br /> I <br /> ,, <br /> l � l <br /> 3 2017 <br /> U;n,C <br /> hj 7AEh'T <br /> I <br /> t <br /> i I I <br /> EP RTMENT USEUJONY <br /> Application Accepted ByAl lk Date Area Employee IDO'�� <br /> Grout Inspeccio "� Date - SPECIAL Well Permit <br /> Pump Inspection By Date _ WAIVER Received <br /> Soil Boring Inspection 8 _ Date C.nnarn,n.a W.0 r-1, w <br />